# A 32-year-old multigravida at 42 weeks gestation is admitted for labor induction due to post-term pregnancy. The cervix is 2 cm dilated, 60% effaced, and the fetal head is at -1 station. Which nursing intervention should be the priority before beginning oxytocin administration? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543014 > language: ko > subject: Maternal Newborn Health ## 문제 A 32-year-old multigravida at 42 weeks gestation is admitted for labor induction due to post-term pregnancy. The cervix is 2 cm dilated, 60% effaced, and the fetal head is at -1 station. Which nursing intervention should be the priority before beginning oxytocin administration? ## 보기 1. Insert an intrauterine pressure catheter to monitor contraction strength 2. Obtain a baseline fetal heart rate strip for 20-30 minutes **✔ 정답** 3. Administer a cervical ripening agent such as misoprostol 4. Place the patient in lithotomy position for cervical examination **정답: 2** ## 해설 Before initiating oxytocin for labor induction, establishing a baseline fetal heart rate pattern for 20-30 minutes is essential to assess fetal well-being and provide a comparison for monitoring. Other options are incorrect because inserting an IUPC or administering cervical ripening agents are not priorities before baseline FHR assessment, and lithotomy position is for examination not a priority intervention. ## 심화 해설 Understanding the Clinical Scenario This question presents a post-term pregnancy at 42 weeks gestation requiring labor induction. The cervical examination reveals 2 cm dilation, 60% effacement, and a fetal station of -1. Before initiating oxytocin, the nurse must prioritize an intervention that establishes fetal well-being and provides a baseline for ongoing assessment. Oxytocin is a high-alert medication that directly affects uterine contractility and can alter fetal oxygenation; therefore, the priority is to confirm that the fetal heart rate pattern is reassuring prior to starting the infusion. Analysis of the Correct Answer (Option 2) Obtaining a baseline fetal heart rate strip for 20-30 minutes is the essential first step. This action aligns with the fundamental principle of assessing the fetus before introducing a uterotonic agent. The baseline tracing documents the fetal heart rate, variability, accelerations, and absence of decelerations. Without this information, the nurse cannot distinguish between a pre-existing non-reassuring pattern and one caused by oxytocin-induced hyperstimulation. In the context of a post-term pregnancy, the fetus is already at increased risk for uteroplacental insufficiency, making this assessment even more critical. The provided evidence underscores the importance of monitoring during induction. For instance, studies on labor induction and management, such as those examining the duration of induction and maternal-neonatal outcomes, inherently rely on continuous or intermittent fetal monitoring to ensure safety during the process [1,4]. The baseline strip serves as the control against which all subsequent changes are measured. Why Other Options Are Incorrect Option 1: Insert an intrauterine pressure catheter (IUPC). While an IUPC provides precise measurement of contraction strength and frequency, it is not the immediate priority. Its insertion is invasive, requires ruptured membranes, and is typically reserved for situations where external monitoring is inadequate or when more precise data on contraction intensity is needed to manage a dysfunctional labor pattern. Placing an IUPC before obtaining a baseline fetal heart rate tracing would bypass the essential step of first confirming fetal well-being. Option 3: Administer a cervical ripening agent such as misoprostol. This action is not indicated based on the current cervical examination. The patient’s cervix is already 2 cm dilated and 60% effaced, which indicates a favorable Bishop score and that the cervix has already begun the process of ripening and dilation. Cervical ripening agents are typically used when the cervix is unfavorable (e.g., closed, thick, firm). Administering misoprostol at this stage could lead to uterine hyperstimulation without first confirming fetal status. The research on labor induction often stratifies patients by the Bishop score, a measure of cervical favorability, to determine the need for ripening versus proceeding directly to oxytocin . Option 4: Place the patient in lithotomy position for cervical examination. The cervical examination has already been completed, as the dilation, effacement, and station were provided in the scenario. The lithotomy position is not a prerequisite for a vaginal examination and is generally used only for specific procedures or during the second stage of labor. Routine use of this position for an exam is unnecessary and can cause discomfort and supine hypotension. Clinical Reasoning and Pathophysiology The priority intervention is driven by the nursing process and safety principles. Assessment must always precede intervention. Before administering a medication that will alter uterine activity and potentially compromise fetal oxygenation, the nurse must assess the current fetal status. The post-term placenta may have reduced functional reserve, making the fetus less tolerant of the stress of contractions. A 20-30 minute tracing allows for the observation of a complete sleep-wake cycle and the identification of a reassuring pattern, which includes moderate variability and accelerations. This baseline is the standard of care for evaluating fetal tolerance to labor, a concept central to all labor management research, including studies on labor dance and epidural analgesia during the first stage [1,2]. ## 임상 시나리오 Clinical Practice Guide Priority Before Oxytocin - Perform a 20-30 minute continuous electronic fetal monitoring (EFM) strip to establish a reassuring baseline (normal rate, moderate variability, accelerations, no late/variable decelerations). - Confirm the absence of contraindications such as vasa previa, cord prolapse, or non-reassuring fetal status. - Document maternal vital signs and uterine activity (frequency, duration, resting tone) before infusion. Oxytocin Safety Protocol - Use a programmable infusion pump with a secondary line port closest to the patient to minimize bolus risk. - Start at a low dose (e.g., 1-2 milliunits/min) and titrate per standardized hospital protocol, typically increasing every 30-60 minutes. - Continuously monitor FHR and uterine activity; immediately reduce or discontinue oxytocin for tachysystole (>5 contractions in 10 min) or non-reassuring FHR patterns. Post-Term Pregnancy Considerations - Assess for signs of uteroplacental insufficiency (e.g., oligohydramnios via ultrasound, meconium-stained fluid). - Anticipate potential for meconium aspiration syndrome; have neonatal resuscitation team on standby. - Educate the patient on the rationale for induction and the importance of continuous monitoring to reduce anxiety. ## 핵심 개념 - **Baseline Fetal Heart Rate** — The average fetal heart rate during a 10-minute segment, excluding periodic changes, assessed before interventions like oxytocin to establish fetal well-being. - **Oxytocin** — A high-alert medication used for labor induction or augmentation that stimulates uterine contractions and can affect fetal oxygenation. - **Post-term Pregnancy** — A pregnancy that extends to or beyond 42 weeks gestation, associated with increased risks of uteroplacental insufficiency and fetal compromise. - **Cervical Ripening** — The process of softening, effacing, and dilating the cervix, often facilitated by prostaglandin agents like misoprostol when the cervix is unfavorable. - **Uteroplacental Insufficiency** — A condition where the placenta fails to deliver adequate oxygen and nutrients to the fetus, a key concern in post-term pregnancies. ## 같은 주제 문제 - [A primigravida at 41 weeks gestation is admitted for labor induction due to post-term preg…](https://mymerci.kr/pages/nclex_q.php?qn_id=543013) - [A primigravida at 41 weeks gestation is admitted for labor induction due to post-term preg…](https://mymerci.kr/pages/nclex_q.php?qn_id=543015) - [A 25-year-old primigravida at 40 weeks gestation with gestational diabetes is admitted for…](https://mymerci.kr/pages/nclex_q.php?qn_id=543016) - [A nurse is caring for a client at 38 weeks gestation who is undergoing a vacuum-assisted v…](https://mymerci.kr/pages/nclex_q.php?qn_id=543017) - [A primigravida at 41 weeks gestation is admitted for labor induction due to post-term preg…](https://mymerci.kr/pages/nclex_q.php?qn_id=543018) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._